What Are OIG Exclusions?

Have you ever heard of OIG exclusions? I hadn't until the other day while chatting with a local Nashville healthcare business owner. It turns out, as a medical provider I should have been aware of this legal branch of government. Although I tend to shy away from topics associated with the law, the legal side of my brain is short a few neurons, I think it's important that nurse practitioners are aware of OIG exclusions and the potential career consequences they present. Are you on the excluded list?

What in the World Does OIG Stand For?

OIG stands for Office of the Inspector General, a division of the U.S. Department of Health and Human Services (HHS). The OIG is on a mission to fight waste, fraud and abuse in Medicare, Medicaid and other HHS programs. No, they don't have a mascot but I think they should. A Medicare beneficiary in a cape, perhaps.

Anyway, the OIG performs audits and investigations enforcing healthcare law particularly in the realm of Medicare and Medicaid. Since most of us as NP's treat Medicare and Medicaid patients, the Office of the Inspector General's decisions and crime-fighting efforts affect us and our practices.

The OIG posts a three minute video on their site further explaining their regulatory role. Watch it HERE if you feel inclined to learn more (I never knew OIG agents had FBI-esque uniforms). All kidding aside, the OIG plays a serious role in the roll out and regulation of healthcare in our country. It's important that we as providers comply with their rules and are aware of their role in our profession.

OK, Then What are OIG Exclusions?

The OIG Exclusions List, officially titled the List of Excluded Individuals/Entities (LEIE) gives the names of providers currently excluded from participation in Medicare, Medicaid and all other Federal health care programs. This means that if you land yourself on the OIG's "out" list, you won't be able to collect payment for services furnished, ordered and prescribed during your exclusion period on any Medicare or Medicaid patients. Not only will you not get paid for treating these patients, you are subject to some serious fines and penalties.

The most common reason individuals and businesses are placed on the OIG's Exclusion list is Medicare or Medicaid fraud. Other reasons for exclusion include conviction of healthcare related fraud, theft, financial misconduct, unlawful dispensing of controlled substances, suspension or revocation of healthcare license and unlawful kickbacks.

Most of us will probably never have to worry about being placed on the OIG's Exclusion list. Unless your practice has some shady booking policies or you are defrauding your sweet, old Medicare patients you are probably in the clear- with one exception. The OIG has recently made defaulting on your federal student loan a punishable offense. That's right, if you aren't keeping up with your loan payments, the OIG can suspend your ability to treat certain patients (or, at least they won't pay for you to treat them) until you pay up. Your employer could also be subject to some serious financial penalties.

Sounds Serious. What are the OIG Exclusion Penalties?

If you treat Medicare or Medicaid patients while on the OIG's Exclusion List, you and/or your employer could face thousands of dollars in penalties. For each case of false or fraudulent claims, the OIG may seek a penalty of up to $10,000 for each item or service improperly claimed. This means $10,000 for each Medicare or Medicare patient you treated while your name was on the list. Additionally, the OIG can seek a penalty of up to three times the amount improperly claimed. For example, if you treated a Medicare patient in the ER for pneumonia you would be fined $10,000 for that patient plus an amount three times their hospital bill.

Some cases have even stiffer penalties. Accused of improper kickbacks? That's a $50,000 fine.

Am I On the List?

Fortunately, you can visit the OIG's website to make sure you are in good standing. Simply type in your name (or the name of a friend or coworker if you're feeling nosey) and the system will pull up your name if you're on the list of exclusions. Many employers will also do this for you on a regular basis to make sure you are in compliance with OIG regulations.

If you think you have violated any of the OIG's rules and regulations or find yourself in trouble, act now. The OIG takes into account when a provider self-discloses a potential act of fraud offering greater leniency in their response to the misconduct.

Hopefully you will never find yourself in any sort of legal trouble concerning your medical license and ability to practice. Even if you never come close to landing your name on the OIG's Exclusion List, awareness of these regulations and penalties could save you a misstep in the future.